This chapter include objectives: Identify the purpose of the patient care report; describe the uses of the patient care report; outline the components of an accurate, thorough patient care report; describe the elements of a properly written emergency medical services (EMS) document; describe an effective system for documenting the narrative section of a prehospital patient care report;...
9/11/2012 Chapter 29 Abdominal and Gastrointestinal Disorders Lesson 29.1 Abdominal Organs and Abdominal Pain Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 9/11/2012 Learning Objectives • Label a diagram of the abdominal organs • Describe the function of the abdominal organs • Outline prehospital assessment of a patient who is complaining of abdominal pain. Learning Objectives • Distinguish between pain characteristics in abdominal pain • Describe general prehospital management techniques for a patient who is complaining of abdominal pain. Gastrointestinal Anatomy • Provides body with water, electrolytes, other nutrients used by cells – Major organs • • • • • • Esophagus Stomach Small and large intestines Liver Gallbladder Pancreas Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 9/11/2012 Acute Abdominal Pain • When abdominal pain is present, begin primary survey by ensuring scene is safe – Initial scene size up – Determine if abdominal pain is result of trauma or medical condition • May be evident from initial scene survey Acute Abdominal Pain • Nature of pain may become evident by obtaining information from patient, family, or bystanders • Inspect nearby area for medication bottles and signs of alcohol or other drug use – May offer clues about cause of patient’s condition – If alcohol or other drug use is suspected, any containers of emesis should be transported with patient for laboratory analysis Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 9/11/2012 Acute Abdominal Pain • After primary survey to ensure adequacy of airway, breathing, and circulation, assessment of patient begins with thorough history focused on chief complaint – Assess and document baseline vital signs and perform systematic physical examination • Helps identify abdominal emergencies • May indicate development of shock or need for immediate transport for surgical intervention 10 History • When obtaining history of abdominal pain, attempt to identify – Location – Type of pain – Associated signs and symptoms • Using mnemonic OPQRST or similar method can help organize this information 11 History • OPQRST evaluation – O (Onset) • Was the onset of the pain sudden? • What were you doing when it started? – P (Provocative/palliative) • • • • • What makes the pain better? What makes the pain worse? Does a sitting or lying position affect your discomfort? Does a deep breath increase the pain? Does the pain change after you eat or drink? 12 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 9/11/2012 History • OPQRST evaluation – Q (Quality) • What does the pain feel like? • Is it sharp, dull, burning, tearing? – R (Region) • Where is the pain located? • Does it travel (radiate) to another area of the body, or does it stay in the same place? 13 History • OPQRST evaluation – S (Severity) • Is the pain mild, moderate, or severe? • What is the degree of discomfort on a scale of 0 to 10 (with 10 being the worst)? – T (Time) • When did the pain begin? • Is it constant or intermittent? • If intermittent, how long does the pain episode last? 14 History • Can use SAMPLE history – Signs and symptoms – Allergies – Medications – Past medical history – Last meal or oral intake – Events before the emergency 15 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 9/11/2012 History • Can use SAMPLE history – Helps identify • • • • • Symptoms Allergies Medical history Last oral intake Events that preceded patient’s chief complaint 16 History • Other important elements: recent illness and past significant medical history – Hypertension or cardiac or respiratory disease that may manifest in abdominal pain – Medication use – Alcohol or other drug use – Last bowel movement and any significant changes in patient’s bowel habits 17 History • Other important elements: recent illness and past significant medical history – Previous abdominal surgeries – Women of childbearing age also should be questioned about menstrual periods • Regularity • Date of last menstrual period – Possibility of pregnancy 18 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 9/11/2012 What factors can influence a patient’s perception and description of pain? 19 Abdominal Pain Location and Type • To assess specific disorder, use method that relates to anatomical location of and structures to origin • Types of abdominal pain that may result from chronic or acute episodes may be classified as visceral, somatic, and referred 20 Visceral Pain • Organ pain – Caused by stimulation of autonomic nerve fibers that surround an organ – Can be caused by compression and inflammation of solid organs and by distention or stretching of hollow organs or ligaments – Patient usually describes pain as cramping or gas‐ type pain 21 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 9/11/2012 Visceral Pain • Organ pain – Patients often describe pain as • Varying in intensity • Increasing to high degree of severity, then subsiding – Generally diffuse – Difficult to localize 22 Visceral Pain • Often pain is centered at umbilicus or lower in midline • Often associated with other symptoms of autonomic nerve involvement such as – Tachycardia – Diaphoresis – Nausea – Vomiting 23 Visceral Pain • Common causes – Early appendicitis – Pancreatitis – Cholecystitis – Intestinal obstruction 24 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 9/11/2012 Somatic Pain • Produced by bacterial or chemical irritation of nerve fibers in peritoneum (peritonitis) – Usually constant – Localized to specific area – Described as sharp or stabbing – Patient is hesitant to move about • May lie on back or side with legs flexed to prevent additional pain from stimulation of peritoneal area 25 Somatic Pain • Often exhibit involuntary guarding of abdomen during physical examination and rebound tenderness (signs of peritoneal inflammation) • Common causes – Appendicitis – Inflamed or perforated viscus (ulcer, gallbladder, or small or large intestine) 26 Referred Pain • Pain in part of body considerably removed from tissues that cause pain – Results from branches of visceral fibers that synapse in spinal cord with same second‐order neurons that receive pain fibers from skin – When pain fibers are stimulated intensely, pain sensations spread – Pain in areas distant from original source 27 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 9/11/2012 Referred Pain • Knowledge is important because many visceral ailments cause no other symptoms except referred pain – Example: • Cardiac pain may be referred to neck and jaw, shoulders, pectoral muscles, and down arms • Biliary pain to right subscapular area • Renal colic to genitalia and flank area • Uterine and rectal pain to lower back • Leaking aortic aneurysm to lower back or buttocks 28 29 Acute Abdominal Pain • Signs and symptoms – – – – – – – – Nausea, vomiting, anorexia Appendicitis Biliary tract disease Gastritis High intestinal obstruction Pancreatitis Diarrhea Inflammatory process (gastroenteritis, ulcerative colitis) 30 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 10 9/11/2012 Pancreatitis • Symptoms – Nausea, vomiting – Abdominal tenderness and distention – Abdominal pain described as severe, radiating from midumbilicus to patient’s back and shoulders – In severe cases • • • • Fever Tachycardia Signs of generalized sepsis and shock Hospitalization 124 Pancreatitis • Treatment – IV fluids – Pain medication – Placement of nasogastric tube if patient is vomiting 125 Esophagogastric Varices • Complex of longitudinal, tortuous veins at lower end of esophagus that become large and swollen as result of portal hypertension – Common in patients with liver disease and often result from portal hypertension caused by cirrhosis of liver – Obstruction to blood flow in liver, produced by fibrosis in liver, increases pressure – Obstruction also dilates vessels that drain into liver 126 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 42 9/11/2012 Esophagogastric Varices • Subsequent dilation of thin‐walled veins around lower esophagus and upper end of stomach produces esophagogastric varices – Varices can rupture • Results in life‐threatening hemorrhage 127 Esophagogastric Varices • Esophageal bleeding causes – Esophagitis • Associated with chronic use of alcohol and anti‐ inflammatory nonsteroidal medications – Malignancy – Episodes of prolonged, violent vomiting that produces tear or laceration in mucosa of upper esophagus (Mallory‐Weiss syndrome) 128 129 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 43 9/11/2012 Esophagogastric Varices • Clinically, patient with esophageal bleeding has bright red hematemesis May be severe If bleeding profuse, melena may be evident Patient may manifest classic signs of shock Variceal bleeding usually is massive and difficult to control – Therapeutic intervention includes ensuring patent airway and fluid resuscitation – – – – • Placement of nasogastric tube for gastric lavage is controversial 130 Esophagogastric Varices • Definitive care – Placement of Sengstaken‐Blakemore tube to tamponade bleeding vessels – Surgical ligation of bleeding varices – Transendoscopic injection of sclerosing agent into bleeding vessels 131 Hemorrhoids • Swollen, distended veins inside anus (internal) or under skin around anus (external) – Common during pregnancy (result from fetal pressure in abdomen and hormonal changes that cause hemorrhoidal vessels to enlarge) – Present in 50 percent of all persons by age 50 – Irritation of distended veins made worse by straining during bowel movements and by rubbing or cleaning around anus, which may produce itching, bleeding, or both – Symptoms subside within few days 132 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 44 9/11/2012 Hemorrhoids • Pain infrequent unless thrombosis, ulceration, or infection is present – Slight bleeding is most common symptom • Usually occurs during or after defecation • Blood dripping into toilet after defecation or blood‐ streaked toilet tissue after wiping are common indications • Blood loss usually slight • Recurrent episodes of bleeding may be significant enough to produce anemia 133 Hemorrhoids • Definitive care – Diet modification – Stool softeners – Tissue fixation techniques – Operative hemorrhoidectomy for severe cases 134 Cholecystitis • Inflammation of gallbladder – Disease is common in U.S – Occurs in 15 to 20 percent of population – More common in women 30 to 50 years of age than in men – Becomes more common with age in both sexes 135 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 45 9/11/2012 Cholecystitis • Risk factors – – – – – – – – Female sex Oral contraceptive use Increasing age Obesity Diabetes mellitus Chronic alcohol ingestion African American or Asian ethnicity May be chronic with recurrent subacute symptoms or acute because of gallstone obstruction 136 Cholecystitis • In 90 percent of cases, caused by gallstones (composed mainly of cholesterol) in gallbladder – On occasion totally obstruct neck or cystic duct of gallbladder • Leads to common bile duct that empties into small intestine – Trapped bile becomes concentrated • Causes irritation and pressure buildup in gallbladder • Can lead to bacterial infection and perforation 137 Cholecystitis • Increased pressure causes sudden onset of pain (biliary colic) – Radiates to right upper quadrant or right scapula – Commonly have pain episodes at night – Associated with recent ingestion of fried or fatty foods – Other causes • Severe illness • Alcohol abuse • Tumors of gallbladder 138 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 46 9/11/2012 Cholecystitis • Other associated hallmarks – Previous episodes – Family history of gallbladder disease – Low‐grade fever – Nausea – Vomiting that may be bile stained and described as bitter (variable) – Pain and tenderness on palpation in right upper quadrant 139 Cholecystitis • Passage of stones into common bile duct with subsequent obstruction may cause – Shaking chills – High fever – Jaundice – Acute pancreatitis 140 Cholecystitis • Treatment – Hospitalization – IV fluid therapy – Antibiotics – Placement of a nasogastric tube • Definitive treatment – Surgical removal of gallbladder 141 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 47 9/11/2012 Acute Hepatitis • Inflammation of liver • Single most important cause of liver disease in • Acute hepatitis – Associated with • • • • • Sudden onset of malaise Weakness Anorexia Intermittent nausea and vomiting Dull right upper quadrant pain 142 Acute Hepatitis • Three classes of viruses that are of main concern as causes of acute infectious hepatitis – Hepatitis A virus – Hepatitis B virus – Hepatitis C virus, formerly known as non‐A/non‐B hepatitis virus 143 Acute Hepatitis • All types produce similar pathological changes in liver – Stimulate antibody response specific to type of virus causing disease • Many hepatitis infections are subclinical – Often present as influenza‐like symptoms 144 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 48 9/11/2012 Acute Hepatitis • Serious condition – Cirrhosis (scarring of liver) – Hepatic encephalopathy (brain and nervous system damage that occurs as complication of liver disease) – Liver cancer 145 146 Acute Hepatitis • Inflammation of hepatitis causes – Alcohol or other drug use – Autoimmune disorders – Toxic bacterial, fungal, parasitic, and viral infections • Require physician’s evaluation and care 147 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 49 9/11/2012 Acute Hepatitis • Proper immunization of paramedics against hepatitis A and B is important • Observation of body substance isolation procedures also crucial when paramedics are caring for these patients 148 Hereditary Hemochromatosis • One of most common genetic disorders in U.S – Inherited condition in which body absorbs and stores too much iron • Extra iron accumulates in several organs, especially the liver, heart, pancreas – Many people have no symptoms, even in advanced stages • Joint pain is most common complaint 149 Hereditary Hemochromatosis • Common symptoms – Fatigue – Abdominal pain – Decreased libido – Heart problems 150 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 50 9/11/2012 Hereditary Hemochromatosis • Symptoms tend to occur in men between the ages of 30 and 50 and women over age 50 • If not detected early and treated by ridding body of excess iron with regular phlebotomy, serious illness (including death) may result 151 Hereditary Hemochromatosis • Systemic illnesses that develop from hemochromatosis include – Arthritis – Liver disease, including an enlarged liver, cirrhosis, cancer, liver failure – Damage to pancreas, possibly causing diabetes – Heart abnormalities, such as irregular heart rhythms or congestive heart failure – Impotence 152 Hereditary Hemochromatosis • Systemic illnesses that develop from hemochromatosis include – Early menopause – Abnormal pigmentation of skin, making it look gray or bronze – Pituitary damage – Damage to the adrenal gland 153 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 51 9/11/2012 Hereditary Hemochromatosis • Defective gene must be inherited from both parents in order to develop disease – Those who inherit defective gene from only one parent usually do not develop it – Siblings of people who have disease should have their blood tested to see if they have disease or are carriers – Parents, children, other close relatives of people who have disease should consider being tested 154 Age‐Related Variations in Abdominal Pain • Many physiological and anatomical differences between infant, child, and adult patients – Abdominal pain may also be quite different – Example • Causes of abdominal pain in elderly are more likely to require surgical treatment • Infants and young children are unable to communicate their history or degree of pain • As result, can become dehydrated and septic more quickly than adults • Vital signs in these groups often do not accurately reflect their degree of illness 155 Why do you think someone would refuse the opportunity to be vaccinated against this deadly disease (hepatitis)? 156 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 52 9/11/2012 Summary • Major organs associated with the GI system include the esophagus, stomach, small and large intestines, liver, gallbladder, and pancreas • After scene survey and primary assessment of patient with abdominal pain, obtain a thorough history – Physical examination may help to determine whether pain is visceral, somatic, or referred 157 Summary • Type and location of pain may help to narrow differential diagnosis • Important signs and symptoms associated with abdominal pain include nausea, vomiting and anorexia, diarrhea, constipation, stool color and fever 158 Summary • Most common treatment for abdominal pain occurs at the hospital – Paramedic should provide supportive treatment, manage life threats, and transport the patient to an appropriate facility 159 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 53 9/11/2012 Summary • Gastrointestinal bleeding can be slow and chronic or rapid and life‐threatening – Causes of GI bleeding include esophagogastric varices, Mallory‐Weiss syndrome, cancer, medication use, and other systemic disease • Gastroenteritis is inflammation of the stomach and intestines caused by infectious agents, chemicals, or other conditions 160 Summary • Gastritis is acute or chronic inflammation of gastric mucosa – Commonly results from hyperacidity, alcohol or other drug ingestion, bile reflux, and H. pylori infection • Ulcerative colitis is an inflammatory condition of the large intestine – Colitis is characterized by severe diarrhea and ulceration of the mucosa of the intestine (ulcerative colitis) 161 Summary • Diverticulosis may result in bright red rectal bleeding if perforation occurs • Diverticulitis results when a diverticulum becomes obstructed with fecal matter • Appendicitis occurs when passageway between appendix and cecum is obstructed by fecal material or by inflammation caused by infection 162 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 54 9/11/2012 Summary • Peptic ulcer disease occurs when open wounds or sores develop in stomach or duodenum • Bowel obstruction is an occlusion of the intestinal lumen – Results in blockage of normal flow of intestinal contents • Crohn’s disease is a chronic, inflammatory bowel disease – Unknown origin 163 Summary • Inflammation of pancreas is called pancreatitis – It causes severe abdominal pain • Esophagogastric varices result from obstruction of blood flow to the liver as a result of liver disease – Rupture of varices can cause hemorrhage and death • Hemorrhoids are distended veins in rectoanal area 164 Summary • Cholecystitis is inflammation of gallbladder – It most often is associated with presence of gallstones • Hepatitis is characterized by sudden onset of malaise, weakness, anorexia, intermittent nausea and vomiting, and dull right upper quadrant pain – Usually are followed within 1 week by onset of jaundice, dark urine, or both 165 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 55 9/11/2012 Summary • Hereditary hemochromatosis is a condition in which the body absorbs and stores too much iron – Can cause severe damage when it collects in the liver, heart, and pancreas 166 Questions? 167 Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company 56 ... Lesson 29.2 Specific Abdominal and Gastrointestinal Disorders 47 Learning Objective • Describe signs and symptoms, complications, and prehospital management for the following abdominal and gastrointestinal (GI) disorders: ... patient’s perception and description of pain? 19 Abdominal Pain Location and Type • To assess specific disorder, use method that relates to anatomical location of and structures to origin • Types of abdominal pain that may result from ... clockwise – Note tenderness and abdominal skin temperature and color – Tympany is major sound that should be noted during percussion because of normal presence of air in stomach and intestines – Dullness should be heard over organs and solid masses